Underestimation of the Presence of Breast Carcinoma in Papillary Lesions Initially Diagnosed at Core-Needle Biopsy1

Virginia Commonwealth University, Ричмонд, Virginia, United States
Radiology (Impact Factor: 6.87). 01/2007; 242(1):58-62. DOI: 10.1148/radiol.2421031988
Source: PubMed


To retrospectively determine the degree of underestimation of breast carcinoma diagnosis in papillary lesions initially diagnosed at core-needle biopsy.
Institutional review board approval and waiver of informed consent were obtained for this HIPAA-compliant study. Mammographic database review (1994-2003) revealed core biopsy diagnoses of benign papilloma (n=38), atypical papilloma (n=15), sclerotic papilloma (n=6), and micropapilloma (n=4) in 57 women (mean age, 57 years). Excisional or mammographic follow-up (>or=2 years) findings were available. Patients with in situ or invasive cancer in the same breast or patients without follow-up were excluded. Findings were collected from mammography, ultrasonography, core technique, core biopsy, excision, and subsequent mammography. Reference standard was excisional findings or follow-up mammogram with no change at 2 years. Associations were examined with regression methods.
In 38 of 63 lesions, surgical excision was performed; in 25 additional lesions (considered benign), follow-up mammography (24-month minimum) was performed, with no interval change. In 15 lesions, 14-gauge core needle was used; in 48, vacuum assistance (mean cores per lesion, 8.7). Carcinoma was found at excision in 14 of 38 lesions. Core pathologic findings associated with malignancy were benign papilloma (n=1), sclerotic papilloma (n=1), micropapilloma (n=2), and atypical papilloma (n=10). Frequency of malignancy was one (3%) of 38 benign papillomas, 10 (67%) of 15 atypical papillomas, two (50%) of four micropapillomas, and one (17%) of six sclerotic papillomas. Excisional findings included lobular carcinoma in situ (n=2), ductal carcinoma in situ (n=7), papillary carcinoma (n=2), and invasive ductal carcinoma (n=3). Low-risk group (micropapillomas and sclerotic and benign papillomas) was compared with high-risk atypical papilloma group. Core findings were associated with malignancy at excision for atypical papilloma (P=.006). Lesion location, mammographic finding, core number, or needle type were not associated (P>.05) with underestimation of malignancy at excision.
Benign papilloma diagnosed at core biopsy is infrequently (3%) associated with malignancy; mammographic follow-up is reasonable. Because of the high association with malignancy (67%), diagnosis of atypical papilloma at core biopsy should prompt excision for definitive diagnosis.

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    • "Only in a limited number of cases surgical biopsies still have an additional value. A surgical biopsy is, for example, justified in case of a non-representative CB and in cases showing high-risk lesions or premalignant findings at CB (Shin and Rosen, 2002; Sydnor et al, 2007; NABON, 2008). Furthermore, a surgical biopsy can be the biopsy-method of choice when patient characteristics (for example, extreme obesity or dementia) impede percutaneous biopsy. "
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    ABSTRACT: Background: Diagnostic surgical breast biopsies have several disadvantages, therefore, they should be used with hesitation. We determined time trends in types of breast biopsies for the workup of abnormalities detected at screening mammography. We also examined diagnostic delays. Methods: In a Dutch breast cancer screening region 6230 women were referred for an abnormal screening mammogram between 1 January 1997 and 1 January 2011. During two year follow-up clinical data, breast imaging-, biopsy-, surgery- and pathology-reports were collected of these women. Furthermore, breast cancers diagnosed >3 months after referral (delays) were examined, this included review of mammograms and pathology specimens to determine the cause of the delays. Results: In 41.1% (1997–1998) and in 44.8% (2009–2010) of referred women imaging was sufficient for making the diagnosis (P<0.0001). Fine-needle aspiration cytology decreased from 12.7% (1997–1998) to 4.7% (2009–2010) (P<0.0001), percutaneous core-needle biopsies (CBs) increased from 8.0 to 49.1% (P<0.0001) and surgical biopsies decreased from 37.8 to 1.4% (P<0.0001). Delays in breast cancer diagnosis decreased from 6.7 to 1.8% (P=0.003). Conclusion: The use of diagnostic surgical breast biopsies has decreased substantially. They have mostly been replaced by percutaneous CBs and this replacement did not result in an increase of diagnostic delays.
    Full-text · Article · May 2013 · British Journal of Cancer
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    • "In some institutions, surgical excision is performed for papillary lesions[57-60]. In a review of 57 patients with different papillary subtypes, Sydnor showed an incidence of carcinoma in benign papilloma of 3% compared with 67% for atypical papilloma[61]. This demonstrates the wide spectrum of papillary lesions and the indications for surgical excision. "
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    ABSTRACT: The aims of this study were to determine the accuracy of concurrent core needle biopsy (CNB) and fine needle aspiration biopsy (FNAB) for breast lesions and to estimate the false-negative rate using the two methods combined. Over a seven-year period, 2053 patients with sonographically detectable breast lesions underwent concurrent ultrasound-guided CNB and FNAB. The sonographic and histopathological findings were classified into four categories: benign, indeterminate, suspicious, and malignant. The histopathological findings were compared with the definitive excision pathology results. Patients with benign core biopsies underwent a detailed review to determine the false-negative rate. The correlations between the ultrasonography, FNAB, and CNB were determined. Eight hundred eighty patients were diagnosed with malignant disease, and of these, 23 (2.5%) diagnoses were found to be false-negative after core biopsy. After an intensive review of discordant FNAB results, the final false-negative rate was reduced to 1.1% (p-value = 0.025). The kappa coefficients for correlations between methods were 0.304 (p-value < 0.0001) for ultrasound and FNAB, 0.254 (p-value < 0.0001) for ultrasound and CNB, and 0.726 (p-value < 0.0001) for FNAB and CNB. Concurrent CNB and FNAB under ultrasound guidance can provide accurate preoperative diagnosis of breast lesions and provide important information for appropriate treatment. Identification of discordant results using careful radiological-histopathological correlation can reduce the false-negative rate.
    Full-text · Article · Jul 2010 · BMC Cancer
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    ABSTRACT: Objective To prospectively determine the upgrade rate following surgery in benign papilloma initially diagnosed at ultrasound (US)-guided 14-gauge gun biopsy. Methods A total of 128 benign papillomas were diagnosed in 114 patients after a US-guided biopsy. Surgical excision was recommended where the biopsy indicated benign papilloma, regardless of imaging findings. The upgrade rate to ‘atypical’ and ‘malignancy’ was measured on a per-lesion basis. We analysed potential associations between clinical presentation, lesion variables and the results of surgical excision (using logistic regression). Results Of the 114 patients, 87 eventually underwent surgery: among the 100 supposed benign papillomas, surgical excision revealed fibrocystic change or no residual lesion in nine cases, intraductal papilloma in 74, atypical papilloma in 13, papillary ductal carcinoma in situ (DCIS) in three and one invasive papillary carcinoma. The upgrade rate for an atypical papilloma or papilloma with adjacent foci of atypical ductal hyperplasia (ADH) and malignancy was 13% (95% CI = 7.1–21.2%) and 4% (95% CI = 1.1–9.9%), respectively. The mean lesion size (P = 0.041) was significantly larger when lesions were upgraded to malignancy. Other features were not significantly associated with pathological underestimation (P > 0.05). Conclusion Surgical excision should be considered for benign intraductal papillomas above 1.5 cm in size.
    No preview · Article · May 2010 · European Radiology
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